GW1-2022-08616_Well Construction - GW1_20220503

1.Well Contractor Informatiio�n: I I
14..WATERZONES
Well Contra torName IFROM I TO I DESCRIPTION
ft !•
/ ft ft.NC Well Contractor Certification Number
15:OvxER:CA.SING,(for multi="ea"iins)q:V M F.R Ira-'lic:ble',1 '.
Morgan Well &Pump, Inc. FROM I TO I DIAMETER THICKNESS I MATERTdx.
Company Name +1 ft ft 1 61/8l I m' sdt21 pvc
�l
C-\,+�J 16:INNERCA INGOR•TUBING. 6eottiermalcto'sed
2.Well Construction Permit#: ( lJV ,rJ FROM TO DIAMETER TXCSNESS MATERIAL
List all applicable well constructionpermits'(ie.WC,Comity,State,Variance,etc)• ft. ft. In.
3.Well Use(check well use): ft. ft. m•
Water Supply Well: 17 SCREEN'.:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural DMuaicipal/Public ft ft in.
i Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. it
Indusin�TCommercial I Residentia]Water Supply(shared) :18:GROUT-.'-.•" .:, -: ''`" :: - -
I hri lion FROM TO MATEPJAL EMPLACEMENT METHOD&_AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
:Monitoling Recovery ft. ft.
Injection Well: ft ft
_J Aquifer Recharge 0 Groundwater Remediation :19.SgND/GRAVEL'PACK tf a"licilile
'Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EN1PLACEMENT METHOD
Aquifer Test 0stormwater Drainage ft ft
Experimental Technology D Subsidence Control ft ft
i Geothermal(Closed Loop) OITracer :20.DRUIZNG-LOG'(atticli additional sVet-trrecess-
Geothermal(Heating J Other(ex lain under#21 Remallcs) FROM
DESCRIPTION(color,hardness,soiUrock
/Cooling Return) f
type in siu etc)
� t y� ft
4.Date Well(s)Completed: ~'Ll L- -- Well ID# ft c ft r j vj r`
5(wa✓.Well Location: Sft J ft B ro VV
i T(11 IL31w, !� 7
Facility/Owner Name Facility ID#(if applicable) ft. ft
0Jft ft
PbysicalAdddres/s,,City,and Zip ft ft C� s.� VF_
cp \ i( Q
County Parcel Identification No.(PIN)
MAY U 3 2079
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one
one lat/long is sufficient) 22_Certification:
N �707g W
6.Is(are)the well(s) (Permanent' or [3Tempor2ry Signature ofCe ed well Contractor Date
By signing this form,I hereby cerffy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or 0I No with 15.4 NUC 01C.0100 or ISA NCACi01C.0200 Well Construction Standm•ds and that a
Ifthis is a repair fill out known well construction information and explain the natut•e of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form 23.Site diagram or additional well details
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
contraction,only 1 GW-1 is needed. Indicate TOTAL N Jlv7BER-of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: v (ft-) 24a. For All Wells: Submit this form within 30 dayt of completion of well
For mulk'ple wells list all depths ifdl ferent(example-3@20 and 2 100)
(� construction to the following.
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10.Static water level below top of casing: 0 (ft) Division of Water Resources,Information Processing Unit,
.Ifwoter level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In•addition to sending the form to the address in 24a
r r L� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method
construction to the following:
(Le.auger,rotary,cable,directpvs1, etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) - Method of test: air pressure 24c.For Water Sunnly&Iniection!Wells: In addition to sending the form to
f the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: ( �� /�G� Amount: t D completion of well construction to the county health department of the county
where constructed.
4
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources -l Revised 2 22-2016
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